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The Affordable Care Act: Overview of Coverage Provisions. Dance/USA 2014 Dance Forum New York, NY January 10, 2014. Sarah J. Dash, MPH Georgetown University Health Policy Institute Center on Health Insurance Reforms. About the Georgetown University Center on Health Insurance Reforms.

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The Affordable Care Act:

Overview of Coverage Provisions


2014 Dance Forum

New York, NY

January 10, 2014

Sarah J. Dash, MPH

Georgetown University Health Policy Institute

Center on Health Insurance Reforms

about the georgetown university center on health insurance reforms
About the Georgetown University Center on Health Insurance Reforms
  • Research and analysis of private health insurance markets
  • Monitoring of state and federal health insurance market regulation
  • Analyze impact on affordability, adequacy, and availability of coverage
  • Projects generously funded by The Commonwealth Fund, Robert Wood Johnson Foundation, and others.
presentation overview
Presentation Overview
  • Health Insurance 101
  • The Affordable Care Act (ACA)
    • Why was it needed and what does it do?
  • How the ACA Expands Coverage
    • Marketplaces (individuals and small businesses)
    • Medicaid
  • Implementation So Far
  • What You Can Do Now
  • Q&A
health insurance 101 where p eople get their coverage
Health Insurance 101: Where people get their coverage

266.4 Million Non-elderly

U.S.: Sources of Coverage for Non-elderly (2011)

Source: Kaiser Family Foundation

health insurance 101 fewer small businesses offering coverage 2003 2010
Health Insurance 101: Fewer Small Businesses Offering Coverage, 2003–2010

Percent of working adults^ ages 19–64

Large firms

(>100 employees)

Small firms

(<50 employees)

Midsize firms

(50–99 employees)

^ Workers include both part-time and full-time workers who are not self-employed.

Source: The Commonwealth Fund Biennial Health Insurance Surveys (2003 and 2010).

why the affordable care act dysfunctional insurance markets
Why the Affordable Care Act? (Dysfunctional Insurance Markets)
  • Access Problems
    • Coverage denied due to pre-existing conditions
    • Rescissions (retroactive policy cancellations)
  • Affordability Problems
    • No employer or other subsidy
    • “Rate ups” for health status, gender, age
  • Adequacy Problems
    • Pre-existing condition exclusions
    • Critical benefits not covered
    • Out-of-pocket costs
    • Annual/lifetime limits on coverage
why the affordable care act everyone feeling the pain
Why the Affordable Care Act? Everyone feeling the pain…
  • For individuals:
    • Barriers to care: prevention and treatment
    • Financial difficulties
    • “Job lock”
    • Personal anxiety, family stress
  • For businesses:
    • Skyrocketing health care costs crowd out higher salaries or other business investments
  • For government:
    • Deficits, budget battles
why the affordable care act many cooks in the kitchen
Why the Affordable Care Act?Many Cooks in the Kitchen…
  • 218 votes in the House
  • 60 votes in the Senate
  • 50 state legislatures, governors, insurance commissioners, and Medicaid directors (plus DC)
  • 17 (ish) directors of state-based Marketplaces
  • 3 federal agencies (HHS, DOL, IRS)

Plus… insurers, doctors, businesses, agents/brokers, consumer advocates, and other stakeholders….


The Affordable Care Act:

How Does it Help Expand Coverage?

key aca coverage provisions
Key ACA Coverage Provisions
  • Availability
    • New rules of the road for health insurance
    • Opens new doors for coverage
  • Affordability
    • More rules of the road for health insurance
    • Financial help with premiums and cost sharing
  • Adequacy
    • New standards for benefits and plan design
aca coverage provisions availability
ACA Coverage Provisions: Availability
  • New rules of the road for health insurance:
    • Prohibits coverage denials/higher premiums based on health status, gender, occupation
  • New Health Insurance Marketplaces
    • One stop shop for coverage, in every state)
  • Medicaid expansion
    • In some states
  • Other coverage provisions:
    • Enables dependents to stay on their parents’health plan until age 26.
critical coverage provisions affordability
Critical Coverage Provisions: Affordability
  • More “Rules of the Road” for health insurance
    • Ends higher premiums based on health status
    • Ban on lifetime and annual dollar limits
    • Limits out-of-pocket costs
    • Insurers must spend at least 80% of premium revenue on health care and quality improvements
  • Financial help for private insurance and Medicaid
    • Subsidies (premium tax credits) for individuals/families with low to moderate incomes buy health insurance
  • Tax credits for small businesses that provide affordable coverage to their employees
critical coverage provisions adequacy
Critical Coverage Provisions:Adequacy
  • Essential health benefits
  • Preventive services covered with no additional cost-sharing

NOTE: Health insurance plan choices may still vary based on factors such as cost sharing, networks, and the extent of covered services!


What Does it Mean for Coverage?

U.S. Coverage in 2019, With and Without the ACA

Private Exchanges

23 million



32 million



26 million



57 million



48 million


Nongroup &


27 million


Nongroup & Other

30 million



161 million



156 million


Without Reform - 2019

Under Reform - 2019

280 Million U.S. Residents Under Age 65

Source: Congressional Budget Office, March 2012 Estimate of the Effects of the Affordable Care Act on Health Insurance Coverage

what else does the aca do
What Else Does the ACA Do?
  • ACA: More than coverage reforms
  • Not discussed today:
    • Delivery system reform
    • Quality improvement
    • Cost containment
    • Public health/prevention
    • Medicare
what d oes the aca not do
What Does the ACA not Do?
  • It doesn’t fix everything all at once for every person
  • It’s not a “government takeover” – builds on current system
  • It doesn’t make health insurance more fun (but it might make it easier)

Opening the Door to

Health Insurance Coverage:

Marketplaces and Medicaid

marketplace basics
Marketplace Basics
  • One-stop-shop for coverage
    • Individuals without other affordable coverage
    • Small businesses (SHOP marketplace)
  • Compare private insurance plans based on price, benefits, quality, and other features
  • Most people will get a break on costs
coverage levels in marketplace
Coverage Levels in Marketplace

% enrollee cost share

% covered by plan

Additional “catastrophic” plan available to individuals under age 30 or if no other coverage is affordable


*All levels have essential health benefits




types of financial assistance individual marketplace
Types of Financial Assistance:(Individual Marketplace)
  • Premium Tax Credits (subsidies)
    • Individuals and families between 100 - 400% of poverty, who aren’t eligible for affordable/adequate job-based insurance, Medicaid, or Medicare
  • Help with Cost-sharing (deductible, copays, and coinsurance)
    • Individuals/families up to 250% poverty ($28,725 individual)

2014: ACA Provides Support Fitted to Income

Family Income

Family income based on 2013 federal poverty income levels for an individual

premium tax credits
Premium Tax Credits
  • Premiums capped at 2-9.5% of income, on sliding scale.
  • Value of credit linked to second lowest-cost silver level plan, but can “go shopping” with tax credit and choose any metal tier level of plan.
  • Tax credits can be paid directly to insurer. Enrollee only owes the difference. Insurers must have ways to accept payments from people who lack credit cards and bank accounts.


Individuals must report changes in income throughout the yearor risk paying back some or all of tax credits to IRS.

cost sharing help
Cost Sharing Help
  • No cost-sharing for recommended preventive services
  • Out-of-pocket maximums ($6350 for individual)
  • Cost sharing reductions: deductibles and copays reduced for families under 250% FPL
shop features of note for small businesses
SHOP: Features of Note for Small Businesses
  • Ability to more easily compare plans
    • Online enrollment starts in 2015 for federal SHOP marketplace
  • “Employee choice”: Ability to give employees a choice of plans
    • Currently available in most state-based marketplaces
    • Starts in 2015 for federal SHOP marketplace
  • Small Business Tax Credit
    • Only through SHOP starting in 2014
timeline for coverage
Timeline for Coverage
  • Individuals:
    • Initial Open Enrollment: October 1, 2013 – March 31, 2014
    • Annual Enrollment: Nov. 15-Jan. 15, 2015
    • Special enrollment periods for qualifying events
    • First effective date is January 1, 2014 (must enroll by December 15, 2013)
  • Small businesses: continuous enrollment
aca s medicaid expansion
ACA’s Medicaid Expansion
  • Before ACA:
    • Medicaid generally not available to single (childless) adults
    • Income eligibility levels vary by state
    • Federal minimum benefit requirements; states may modify
  • After ACA:
    • States may choose to make single (childless) adults eligible up to $15,856 for a single person
    • Expansion decisions vary by state
    • Required “benchmark” benefit package must cover Essential Health Benefits; may vary from state to state
coverage gap for people in poverty
Coverage Gap for People in Poverty

Source: Kaiser Family Foundation

aca implementation so far
ACA Implementation So Far
  • States of the States:
    • Insurance Market Reforms: Most (but not all) states are enforcing the market reforms
    • Health Insurance Marketplaces: 14 states plus DC fully running individual and SHOP marketplaces this year
    • Medicaid: 26 states expanded to date
  • Some Bumps in the Road to be expected…
  • But Enrollment is Picking Up
states running their own marketplaces
States Running Their Own Marketplaces
  • California
  • Colorado
  • Connecticut
  • District of Columbia
  • Hawaii
  • Idaho (in 2015)
  • Kentucky
  • Maryland
  • Massachusetts
  • Minnesota
  • Nevada
  • New Mexico (SHOP only)
  • New York
  • Oregon
  • Rhode Island
  • Utah (SHOP only)
  • Vermont
  • Washington

The Affordable Care Act:

What Dance Artists and Companies Need to Know

what individual dance artists need to know
What Individual Dance Artists Need to Know
  • Responsibility for obtaining coverage (individual mandate)
  • How to access coverage(Marketplaces/Medicaid)
  • Other coverage options
  • What to look for in health insurance coverage
  • How to get assistance
what small companies need to know
What Small Companies Need to Know
  • No responsibility to provide coverage if <50 full-time employees
  • SHOP Marketplaces
  • Small Business Tax Credits
  • How to get help
what large companies need to know
What Large Companies Need to Know
    • Employer responsibility to provide affordable, “minimum essential coverage” if > 50 full-time employees (enforcement delayed until 2015)
  • SHOP Marketplaces open to employers up to 100 employees in 2016
  • Other requirements applying to large employers
    • Not all requirements apply to self-insured or “grandfathered” plans
how to get moving on finding coverage
How to Get Moving on Finding Coverage
  • Explore current coverage options
  • Visit
      • Links to Marketplaces in every state
      • Create an account
      • Get personalized help:
        • Availability of free “assistors” or agents/brokers
        • “Live talk”through call centers or “live chat” on
ways to enroll
Ways to Enroll
  • In-person Assistance:
  • Agents/Brokers
  • Navigators
  • Certified Application
  • Counselors
some special considerations for dance artists
Some Special Considerations for Dance Artists
  • Know what you are buying
    • Marketplace vs. non-Marketplace coverage
    • Understand the tradeoffs (low premiums=higher cost-sharing)
    • Understand terminology (deductible, co-pay)
    • Carefully review benefits in each plan
    • Tobacco “surcharge”
  • Provider networks and out-of-network benefits
  • Estimating income and reporting changes
thank you
Thank you!

Sarah J. Dash, MPHGeorgetown Health Policy Institute

Center on Health Insurance Reforms